Episode 154: Optometric Insights w/ Dr. David Kading
This week Dr. Chris Wolfe and Dr. David Kading sat down to discuss myopia management and implementing it into their practices.
Read the full transcript below:
[00:00:00] Chris: I see that you have a picture of Abraham Lincoln behind you. Do you know what my son, my first son's name is
[00:00:06] David: Lincoln. It is Lincoln.
[00:00:07] Chris: Yep. Why do you have any picture of ever him Lincoln
[00:00:09] David: behind you? My, my first son's name was going to be Lincoln. But I didn't have a son had I had a son. His name probably would have been Lincoln.
[00:00:20] Yeah. I, I'm a, I'm a big fan of of the fortitude that he is that he has put up with. I also have a George Washington right behind me and offscreen. We have Ronald Reagan, but I think too you know, I think particularly since you asked about Abraham Lincoln, just the, the test. Th that man went through as in his presidency, in an effort to bring about unification.
[00:00:47] I think the, the reality of of keeping a country United, despite the fact. That he likely disagreed so wholeheartedly with half of the country is, is just a really, really incredible way that he saw the way he sought wisdom from, and, and, and, and the struggles that he went through in his family.
[00:01:11] And. I think is his strength to spirituality definitely spoke to that and he kept pretty good wit about him during the entirety of it. So I think there's a lot we can learn from the wisdom of Lincoln. I think
[00:01:23] Chris: we can't learn that we couldn't have picked up from something that was just developed yesterday.
[00:01:27] Don't you know, that, you know, I think it is insane. I I think I've said this before, and I've, I've delved deep into it with a number of my conversations and they're not necessarily optometry related, but I do think it's relevant to, you know, what we're doing with my opiate management, what we do with early AMD treatment, glaucoma treatment, dry eye treatment.
[00:01:49] It's like, people just don't have conversations anymore. It's why I love doing podcasts like this. I mean, it's mostly selfish on my part, but people don't know how to You know how to like, just figure out ways that, that we can not agree to disagree, but like where, where am I struggling with something that you're saying and how do I overcome it?
[00:02:10] And one of the things that in my opiate management that I heard you say I just disagree with, and I don't think that it makes you a bad person. You agree with everything I say? Yeah. Except for this one thing.
[00:02:26] Hello and welcome. First of all, podcast on. Today. I had a great conversation with Dr. David Kading, who practices in Seattle, Washington. And he does a lot of primary eyecare stuff. But specifically today we talked about myopia management. It was a lot of fun having a conversation with him about that, and hope you enjoy our conversation as always be sure to subscribe to the podcast, write a review, share it with your friends and support those who support us.
[00:02:53] We've been providing my opiate controlled treatments in our practice for years. If you've been listening to the podcast for a while, Cooper vision has received FDA approval of its innovative myocyte. One day contact lens. This will be the cornerstone of a comprehensive myopia management approach to be offered by CooperVision.
[00:03:10] This daily where single use contact lens is the first and only FDA approved product clinically proven to slow the progression of myopia when initially prescribed for children eight to 12 years old. And when compared to children in the control group, wearing a single vision one day contact lens, check out the show notes for all the specific prescribing details and to get more information about this lens and how you can begin to offer it to your practice.
[00:03:54] Yeah, I think you know, to me, what's really interesting. You're doing a lot of stuff with my opiate now, but what's really interesting to me is as I think back, you know, you were sort of a dry guy for a long time and I still suspect you are, is that a correct assumption?
[00:04:08] David: Yeah. It's funny. You should mention.
[00:04:13] So I was I was consulting with some companies and I'm working with Mila, Jack, who is my counterpart in a lot of things. He said, Dave, I don't, I don't think they know that you do dry eye. So I had this conversation with this person and they're like, I thought you were the specialty contact lens person, like the keratoconus, like the big contact Glen sky.
[00:04:33] And so I explained to him, yeah, pretty big dry eye practice. That's a, that's a big part of who we are and what we. And then fast forward, another couple of years, Mila was doing some scleral lens workshops and, you know, doing some things. And he mentioned to this person, who's in a specialty contact lens arena that I did scleral lenses.
[00:04:53] And they're like, really? I thought he was a dry eye. Right. And it's, so it's kind of like in the sphere that you see me, but I've been doing myopia management since 2004, 2005. My, my mentors were doing a lot of orthokeratology. I remember the conversation in the in, in the lounge during my residency where Pauline Chu's original study came out on slowing the progression of myopia with orthokeratology and my wife was doing her binocular vision and pediatrics residency, and I was doing my.
[00:05:21] And my mentors like this is perfect for you guys. This is going to be a big part of your practice moving forward. That was Patrick Caroline, because you do pediatrics and contact lenses and you like doing north. Okay. That was a right off the bat.
[00:05:35] Chris: Well, Patrick county specific.
[00:05:36] David: Okay. Yup. Yup. So I did my residency at Pacific.
[00:05:39] So since then, yeah, we've had a pretty big myopia management practice all the way back and you know, doing soft multifocals, as soon as they came out, obviously we've done orthokeratology from the beginning and you know, Ortho K meetings, myopia management meetings all the way back, 2005, 2006, 2007. So on my podcast, I interviewed Craig Norman and he's like the funny thing about my opiate management is it's an overnight 30 year success.
[00:06:05] Right. It's taken 30 years to get. But now it's all of a sudden becoming popular and it's been great. I've lectured all over the world about myopia management. And now it seems to like hit this tipping point, right where we're there large part due to Cooper vision and their incredible work worldwide.
[00:06:22] I just met with them on their six year data with the seventh year data being the, where they dropped people out of the treatments, some really cool data we're going to be seeing, coming out it at the upcoming meetings and, you know, in the literature. The evidence of six, seven years of ortho care of myopia management with soft lenses in the buy site.
[00:06:42] So really cool stuff. So yes, I am a dry eye person and I do specialty contact lenses and myopia management. And then the fourth pillar and our office, we've got four that we really stand on is binocular vision in pediatrics, which my wife has a vision therapy practice. I
[00:06:59] Chris: love that because. You know, I think you and I, while we don't know each other very well, I think we look at the profession and our, our role as primary eyecare providers.
[00:07:08] Very similarly in that. I think if you understand the evidence behind what you're doing with managing specific disease state, Then you can do them at a very high level, a very high level. And and if you can overcome the ability, the, the thinking of like, how do I incorporate this into my practice in a way that's not, that's not going to be so disruptive.
[00:07:30] Like there are a few people, I think I suspect you're one of them. Can take any thing like any disease state and be like, we can make this work being, this is how we're going to do it, but, but really many docs just struggle with this idea of like, how do we do this? How do like, when I, when I talk about myopia management, you see this as well is well, how do we charge for.
[00:07:53] Or how do I set up a program around this? Or like, it's not that, like, it's not the stuff about how do we manage my opiate that actually, as you point out with my site, it's like, can be very straightforward. Now. I'm not saying it's simple, but it can be very straightforward, but they're not struggling with that stuff.
[00:08:10] They get it, they get the evidence, they get the, the way to do it. It's like, how do I do this in a way that doesn't completely disrupt my practice? When you, when you see guys and you talk to guys all across the world that are doing a lot of this do they look at primary care the same way, or they just have, have sort of gotten this into us, a specific niche?
[00:08:30] What are the things that you see that hold people back from really embracing my opiate management at some level?
[00:08:37] David: Yeah. Well, I think you nailed it in that So often times the business side of optometry cripples us from performing at the clinical level that we should be. And it it's, it's so true that we're not performing to our full potential.
[00:08:57] Not because we don't know. But because we don't know how to do it or how to implement or bring it in. I think myopia management is certainly one of those avenues and you know, due to the great work of so many people that are in the space. With it growing in the space with J and J coming in with Essilor coming in and Hoya we've got four to six different attribution companies, others that are doing work right now as more and more of that comes in, there's going to be this mainstream perspective of how we utilize it.
[00:09:32] And one thing that. Probably do poorly and I care is we allow a specialty to be come really washed out. So that we're not performing the level of the specialty that we should because we've kind of watered it down and, and neutralized it a little
[00:09:52] Chris: bit. So I want you to give me an example of that specifically with myopia.
[00:09:58] David: Well, my opiate management, I don't think that we're there yet. Okay.
[00:10:01] Chris: So give me an example of something
[00:10:03] David: else. Actually, I will with myopia management. So I think that there's going to be an aspect of it with the spectacle lens is coming into the space where it may be. People don't dig into the technical aspects of who may be better with spectacles versus soft multifocals versus actual pain.
[00:10:22] And they may just say, well, I don't like to fit those contact lenses. I'm going to just water it down and put everybody into the one treatment and just see how it
[00:10:29] Chris: works to worry about professional fees. I don't have to worry about any of my additional time. It's just a normal con, a normal prescription.
[00:10:36] I'm gonna write.
[00:10:37] David: Yeah. Yep. And although those products are likely to get, become more expensive and so forth, they'll their costs will come down and, and I think both you and I agree that the more patients have access to things, the better it is. We need to support ourselves as a profession on the financial side.
[00:10:53] But I think that we may water things down a little bit as our access to things becomes a little bit better. And just because it's more available doesn't mean that we shouldn't still. Good at knowing the differentiation. We could probably say the same thing with glaucoma medications over the years, how there is a difference between the medications.
[00:11:13] And there are certain ones that perform a little bit better, but I don't think we're having some of those same discussions around this one works better for. The patient and this one may work a little bit better for this. I think we will see that at some point with myopia management. And I think the important thing for those of us that are educating people on myopia management is to make sure people understand that there is a differentiation and there are people that are better with orthopedic.
[00:11:38] There are better people who are maybe better with soft lenses. There may be people who have better with atrazine. And how do we incorporate these into the different aspects of our practice in order to maximize the treatment outcome? I want to, I want to speak to that just for a
[00:11:51] Chris: second. Yeah. That's exactly what I was going to ask.
[00:11:55] Yeah, I was going to ask you, give me an example of where you think one of those would be superior to another. And what would you look at clinically? Sure. Yeah. Yeah,
[00:12:03] David: sure. Yeah. Well, certainly for, we start myopia management at one or two years of age in our practice and I'm not going to fit that child with the north OK.
[00:12:12] Lens. Although they do all the time in Asia, but I may start that patient with a an actual pain. And in those examples, just the other day, we had a patient who is in a soft multifocal and came to the practice. And he's losing his lenses all the time at school because his eyes are drying out with a soft lens is he's six years old.
[00:12:30] He rubs his eye, his lens falls out. Right. And he's having to wear a mask at school all the time. Well, he, we really should move him into orthokeratology. It's going to be a lot easier for the parent. You know, the, the school teachers are not putting contact lenses in his eyes. So those are, those are some examples.
[00:12:46] I think we. Look to the studies to tell us a little bit about how effective the treatments are. And talking with Patrick Caroline about this, we were talking about way that clinical studies are done. So if somebody is in a, my site study and they're a non-responder, but according to their study, about 10% of people were, if you take those 10% of non-responders out of their day, The data actually shows that it's a better treatment than if you include the non-responders right.
[00:13:17] Well, you and I in clinical practice, yeah. You and I in clinical practice would never let those non-responders stay in treatment. We would switch things. So it tends to be that in clinical practice, we always do far more effectively in my opiate. Then the studies indicate. So if you see an ortho case study or a soft multifocal or an , if you were in clinical practice, you would track that patient.
[00:13:43] And if something's not going well, you're going to switch them out of that treatment and try something different. Thus, your effectiveness in myopia management is going to be.
[00:13:52] Chris: Yeah, that's really interesting. I mean, I make the comment all the time when I'm talking about orthokeratology and myopia management, that if you look at, just do a quick meta analysis of all the main studies we've got on orthokeratology, you can get right around 50% reduction and myopia progression.
[00:14:07] Some are, you know, 15 points, higher someone. 15 points lower. But but my, my clinical observation and I always say this and I can't, again, I I'll say I don't have a study for this. I can't explain why that's the case. But my clinical observation is that most of my patients that have been in orthokeratology for 6, 7, 8, 9 years are dead stable.
[00:14:29] And it's probably the case that that some of what you're talking about comes into.
[00:14:35] David: Yeah, well, I'll also mention with, okay, we we've historically had a perspective of what an orthokeratology lens should fit like, right. And we were all taught that in optometry school, large blue ring, huge treatment zone.
[00:14:49] So there's not glare shadows and aberrations. And we've now come to discover that quite possibly. That's not the most ideal myopia management you know, the fit that we would have, and we've seen smaller treatment zones. Usually that includes a smaller optic zone of the lens and there's debate on what a treatment zone looks like.
[00:15:10] But smaller treatment zones tend to provide. Better myopic management effect. And we've got data's from the studies that are showing that. And there's also some interesting studies that that you may have seen that talk about higher order aberrations are better at slowing the progression of myopia.
[00:15:28] And what, what, why that's important is I was talking to my good friend, Randy Kajima, who's kind of the, the big brother of all topography. And he was talking about. Visiting China and they are ortho K fits all over the place. Super sloppy. So does that mean it's not working well, lo and behold, this particular study showed that higher order aberrations coma and spherical aberration, which coma tends to be induced when a lens is de-centered actually may slow the progression of myopia better now in no way am I.
[00:16:01] Fit and improper looking lens and have it be super bad and have three diopters of astigmatism, but maybe that patient who's coming in who's 20, 25 plus, and their lens that fit is just a little bit temporal more than I want it to be, but the patient's doing fine and they're seeing great.
[00:16:20] Chris: happy.
[00:16:21] David: we're slowing the progression of their myopia better than if we had fixed it. And so those are some interesting aspects on ortho K that just have really rung rung true with me
[00:16:30] Chris: recently. I've been, I've been really, you know, I heard your talk at, at division choice exchange about this and I've been kind of, you know, everybody that does orthokeratology when we present cases, we want to present like the best case.
[00:16:43] And we don't want anybody to challenge why we didn't make this other little modification. Right. But like I'm with you. I mean, there's times, and it's not, it's not infrequent. And I think that's part of what you learn in clinical practice that maybe is hard to learn in a, in a university setting or in a residency setting, depending on where you're at.
[00:17:01] Is that, is this idea that, well, how much further do I need to go? How many more times do I see this patient back to try to make perfect when a patient's completely happy and we're, and we're doing what we set out to do. And especially when you present that, that information, it makes. You know, again, my, all my thought is, well, look, if the P like you said, patients happy, you know, corneal staining, exceptable over refraction.
[00:17:25] No. You know, and, and T TA typography is not perfect. What it makes me think of is that more people ought to communicate those kind of nuances in their case presentations during, during CE lectures of like, saying like, look, this doesn't have to be perfect. Aim for perfection, but, but the reality is is you can be completely fine without it.
[00:17:47] And knowing when to stop. I think that's the biggest challenge for a lot of docs to say, go, when do I go in this? Doesn't look perfect. Why isn't it? Perfect. And then they think perfect is the, is the only thing. And it's the enemy of, of acceptable and really actually quite good.
[00:18:02] David: Yeah, I couldn't agree with you more.
[00:18:04] The, the, the only thing I would add is that, do we know what perfect is? Maybe we're thinking perfect is one thing where, when I do orthokeratology for a myopia management, I'm doing it to slow down the progression. And maybe what we used to think is perfect, actually. Isn't right. And your, your point in case of you know the topography may be being off.
[00:18:29] And I think that that may be the biggest thing that has improved my success in practice. And I have to work this out of my residents. I have two residents in the office and I have to work out of them. Perfection quote, perfection. I have to work that out of them in, in, in a true private practice type of setting, a true clinical practice of, of what is perfect.
[00:18:52] And Gary Gerber. And I kind of agree on this and we've talked about this with. People in the myopia management spaces, oftentimes when we are doing myopia management, the reason why it fails is because we're not meeting the expected visual acuity that the parent had in mind. And I don't do myopia management with an intended purpose of a refractive.
[00:19:18] Correct. I do myopia management with the intended purpose of slowing the progression of myopia as much as I can. And when we go into it with that, I think we become more successful. For instance, what's your anticipated visual acuity, Chris, when you use atrazine alone on site.
[00:19:38] Chris: We're just by itself with, without glasses.
[00:19:41] Yeah, not good. Yeah. It's got to be whatever their best their uncorrected vision is.
[00:19:46] David: So, so when we're using other treatments for the intended purpose of slowing the progression of myopia, I think we should think about it somewhat similar to how we do with atrazine, but it just happens to be. That we get them to see better.
[00:20:01] Right? So a small optic zone with orthokeratology a small treatment zone. Isn't going to give as good, a visual acuity as a large treatment sewn might for somebody. And so I right off the bat tell my patients, you know, there's a really good chance that you're going to have to wear glasses. In addition to the treatment that we're using for certain activities.
[00:20:24] There may be times where you're sitting in the back of the room and you need to wear a pair of glasses. That's going to give you a little bit enhanced visual acuity or, or vision, and, you know, kind of joke with the kids. If you're ever become a, you know, a military sniper or a fighter pilot, we're going to have to wear glasses occasionally for that, but pointing out to the parent right off the bat, I'm shooting for this top line on the.
[00:20:46] That's where I'm at now. And you, and I both know a lot of times when ortho cake, when myopia management kids come in, they're seeing like 20, 60, and then the parents gripe that we're not 2020 plus. So I kind of tell them with this treatment we're shooting for 20, 30 or 20, 40 interesting. Often times we get 20, 25 or 2020, but if we miss a couple letters of that I chart and we need to give them a minus a quarter or a half a diopter, a sill or whatever it is.
[00:21:14] Fine tune that vision. We become really successful, whereas it oftentimes was that I fixed the myopia management, but I was seeing the patients back for two or three or five more visits to get that one line of one more letter, one more line of acuity. We're really. We were making the parents upset because they thought we were failing.
[00:21:38] And we also were discouraged that we couldn't fix the myopia management problem. That is potentially the greatest things that I have done for success. Many of the myopia management studies that are out. They don't have 2020 is the outcome. Right? Right. The smart study was 20 to 25. Right. So I think that's a really key component.
[00:21:59] I think that we can all remind ourselves of including myself when I'm seeing patients is what's the outcome we're shooting for number one, slow the progress.
[00:22:10] Chris: Yeah, I think so. I think that's another hurdle that mentally probably you and I need to make sure we're talking about from the podium is, is the, or even just on shows like this is that, you know, doctors or specifically optometrists are really uncomfortable.
[00:22:24] With not 2020, right. We're not comfortable with that. It's sort of beaten into our head in school is if a patient died 2020, why aren't they in 2020? And if we can't explain it, what's going on. Right. And so having that understanding and having enough of those under your belt to know that it's okay is I think super simple.
[00:22:44] Cause, cause again, if I'm looking at it from a standpoint of how do we make less doctor, how do we make more doctors provide more access points to patients for this type of treatment? And one of it, one of the biggest things is getting them comfortable with this idea that they might be a shaky 20, 25 or 2030.
[00:23:01] And, and that's okay. And And when that happens, it's to be expected in, in many cases. And and you can continue on forward as opposed to feeling like, oh, I got to give up and go back to normal.
[00:23:14] David: Yeah, yeah. To be clear, the vast majority of my patients are 2020 minus one. Minus for those of us that are listening, we certainly know that there are some that are 2030, and it may be that we can't get them any better because of the higher order aberrations.
[00:23:31] As previously stated could be a really good thing. We don't know. So I, I agree with you. We have to be okay with that and, and recreating what the expectation is. Moving from, moving into the treatment is really where that starts. And I think that's the reason why historically many people didn't do myopia management when it was just ortho.
[00:23:52] K as they thought. You know, that's too too hard to do. And something like the smart study showed that with one set of lenses, you can be about 90% successful on the first try 96% with one lens change. So that's, you know, ortho K is not a really tough thing to do to get started. And I would say that if you've made one lens change or two lens changes and it doesn't work, try something different, right.
[00:24:18] You're going to be successful. And with soft multifocals as well as they're working, but some kids do struggle with the visual acuity with that. Right. Because of that ad power, their pupil size, they may be 20, 25 and as stated that's okay. Yep. Yeah, they'll get by.
[00:24:35] Chris: Yeah. So I see that you have a picture of Abraham Lincoln behind you.
[00:24:39] Do you know what my son, my first son's name is Lincoln. It is Lincoln. Why do you have any picture of Abraham
[00:24:45] David: Lincoln behind you? My, my first son's name was going to be Lincoln. But I didn't have a son had I had a son. His name probably would have been Lincoln. Yeah. I, I'm a, I'm a big fan of of the fortitude that he is that he has put up with.
[00:25:03] I also have a George Washington right behind me and offscreen. We have Ronald Reagan, but I think too you know, I think particularly since you asked about Abraham Lincoln, just the, the tape. Th that man went through as in his presidency, in an effort to bring about unification. I think the, the reality of of keeping a country United, despite the fact that he likely disagreed so wholeheartedly with half of the country is, is just a really, really incredible.
[00:25:40] Way that he saw the way he sought wisdom from, and, and, and, and the struggles that he went through in his family. And. I think is his strength to spirituality definitely spoke to that and he kept pretty good wit about him during the entirety of it. So I think there's a lot we can learn from the wisdom of Lincoln.
[00:25:59] There's nothing. We
[00:26:00] Chris: can't learn that we couldn't have picked up from something that was just developed yesterday. Don't you know, that, you know, I think it is insane. I I think I've said this before, and I've, I've delved deep into it with a number of my conversations and they're not necessarily optometry related, but I do think it's relevant to, you know, what we're doing with my opiate management, what we do with early AMD treatment, glaucoma treatment, dry eye treatment.
[00:26:25] It's like, people just don't have conversations anymore. It's why I love doing podcasts like this. I mean, it's mostly selfish on my part, but people don't know how to You know how to like, just figure out ways that we can not agree to disagree, but like, Where, where am I struggling with something that you're saying and how do I overcome it?
[00:26:46] And one of the things that in myopia management that I heard you say that I just disagree with, and I don't think that it makes you a bad person. You
[00:26:54] David: agree with everything I
[00:26:55] Chris: say? Yeah. Except for this one thing. And you made the comment. So when I, when I heard you talk and it was like great talk, but this is, but you brought up the point about how do we figure out ways where people disagree?
[00:27:08] And I think a microcosm of that is probably my opiate management. You know, you hear people talk about, you got to have an axial axial length, or you're not doing this well, or you got to have this, you got to do that. Or you got to use this program. I, so the thing that I want to kind of hash out with you and I would love, I would love to change my mind on it, but you made the point.
[00:27:28] When you have a patient that has that you're intervening with my opiate management on, you said well, I would start off with multiple treatments at once. And my approach is like, well, this is like glaucoma, right? Like I'm not going to start out with most patients. Now I could see certain circumstances.